Q: As the daughter of two 88-year-olds and the daughter-in-law of a 96-year-old, I read your column regularly. I was hoping you could address the needs of the elderly in terms of ER visits, or appropriate alternatives. Recently, my father-in-law asked that my husband take him to the ER because he was constipated. My husband was acutely sensitive to the fact that the physician on-call was not pleased that they went to the ER for this issue, although my father-in-law was blithely unaware of the doctor's displeasure. Follow-up with a gastroenterologist resulted in addition of fiber to his diet and a strong admonition that the ER is not the place for this type of concern. Shortly after, my father-in-law again demanded a trip to the ER because he had not been urinating. My sister-in-law has opined that he panics in such instances because he is convinced he is replicating the pattern of a relative who passed away when his "body shut down." I may be wrong, but it is my belief that the ER is truly for life-threatening issues and that waiting until your physician's office opens to make a call or even going to a walk-in clinic is preferable to going there. I was hoping that you could offer some guidance in terms of how to make appropriate decisions and take appropriate action. My husband or his sisters generally attend my father-in-law's doctor appointments with him, but I don't think that they find his primary doctor that helpful.

Marlene

A: You represent a large population of frustrated family members trying to help their loved ones while navigating our health care system. We hear from them in our practice often and I suspect other doctors do as well. There are two separate issues we will need to discuss. One is how the ER works and why it is so hard sometimes to get care quickly there. The other issue, of course, is why, all of sudden, you have had to make all those trips to the emergency room with your father-in-law.

The emergency room concept is similar to a disaster or a war-like situation. Everyone wants to be seen at once but it is not possible. Because of that, there has to be a system of choosing which patients will be seen first and which will have to wait. As a rule, most emergency rooms divide patients into three categories -- very sick and requiring immediate attention; somewhat stable and capable of waiting a little, and not an emergency at all. As you correctly implied, your father-in-law belonged to the last, the "not sick at all" group.

This classification is initially done by a nursing triage staff. After that, every patient in each group is lined up and waits for a doctor or a physician assistant to see them. Even if you are in the "very sick" group, another person may be sicker than you are or might have gotten to the ER earlier. Aside from true life-threatening situations, this is how patients are divided.

The important thing to understand is that what appears to be emergent to the patient and /or their family may not be emergent at all to the ER doctor. This is why the doctor the other day was so stern about your father-in-law and his ER trip.

As a rule, chronic issues like pain, fatigue, constipation, difficulty urinating and so on do not have to be treated at the emergency room at all. Doctors and nurses in an emergency room always first check how likely a given complaint is to be serious or potentially life-threatening, and how likely a given patient is to get worse quickly. This is done by getting such vital information as patients' blood pressure, pulse, temperature and how fast they breathe. All of these measurements can be done rather quickly and are repeated periodically while a person is in the ER. If you are stable and get assigned to the "not as sick" or "not sick at all" group, you may end up waiting for quite some time, -- even hours -- before the doctor will get to you.

Once you get seen by a doctor, what he or she will try to do is eliminate the possibility that your condition is a disaster waiting to happen. The doctor will do tests and blood work and may even request a consultation from a specialist. If the physician is sufficiently reassured that a given complaint is not an emergency, he or she will try for the patient to reconnect with a primary doctor.

Does this mean that we should not come to the emergency room? Not at all. At any time, if people are worried or scared that they may have a life-threatening condition, getting checked in the ER is the right thing to do. The rules of the ER will apply, however, and we need to be prepared for them in advance. That is the point that I guess you were concerned about. Neither of the emergency room trips with your father-in-law were for life threatening conditions.

This brings me to the second part of this story and the question you were asking. Is it possible that your father-in-law is scared now and super sensitive because of the relative who passed away? There is also a question of the role of the primary care physician and his or her responsibility for the situation. An elderly person may often feel insecure about his or her health and may be lonely, or even depressed. They may get overwhelmed with simple daily life chores. But there are ways to help.

The simplest thing is to make sure that your dad-in-law sees his primary doctor quite often and is always prepared for the visit. Family members may help by gathering the symptoms mentioned between appointments and keeping track of them and then bringing the list to the doctor. You may inquire the evening before the visit about what issues need to be addressed there. Have one family member take responsibility to be the main "helper." Do not leave the doctor's office without a plan for the most pressing complaints.

The second, even more important, responsibility is to make your family member socialize more. Each person in the family should contribute some time to pay a visit or take your father-in-law out. This should be done on a regular basis. Insisting on senior center visits and or reconnecting him with his friends will help as well.

Whatever you decide to do, do not depreciate his worry. He is genuinely scared. His feelings need to be validated. People around him are still easier to change and to adjust than he is. I hope you all realize that.